MARRIED
ADOLESCENTS
Married Adolescents
NO PLACE
OF SAFETY
1
World Health Organization & United Nations Population Fund
WHO Library Cataloguing-in-Publication Data
Married adolescents : no place of safety.
1. Marriage. 2. Women's rights. 3. Child welfare. 4. Pregnancy in adolescence. 5. Pregnancy
complications. 6. Adolescent health services. 7. Developing countries. I. World Health
Organization. II. United Nations Population Fund.
ISBN 92 4 159377 6
(LC/NLM Classification: HQ799.2.M3)
© World Health Organization 2006
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Printed by the WHO Document Production Services, Geneva, Switzerland
2
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Contents
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
What do we mean by early marriage? . . . . . . . . . . . . . . . . . .
6
Early marriage declining — but still far to go . . . . . . . . . . . .
9
Sexuality and health in early marriage . . . . . . . . . . . . . . . . . 11
Early marriage often leads to unsafe sex . . . . . . . . . . . . . . . 14
Early marriage may be driven by fear . . . . . . . . . . . . . . . . . 17
Gap between marriage and first child is falling . . . . . . . . . . 19
The risks of early pregnancy . . . . . . . . . . . . . . . . . . . . . . . . 22
Married adolescents miss out on health care . . . . . . . . . . . 26
Programmes to reach married adolecents:
programmes to delay marriage
. . . . . . . . . . . . . . . . . . . . . 29
Married adolescents : no place of safety was written and produced for WHO
by Peter McIntyre, Oxford, UK.
Cover photo by Sandeep Saxena, Frontline Magazine, India, shows an adolescent bride at a temple
near Jaipur the day after her wedding.
Title page photo by © Adam Hinton/ PANOS PICTURES
Preparing a wedding day veil in Donetsk, Ukraine.
Much of the material for this document was provided or suggested by experts of the World Health Organization, the
United Nations Population Fund, The Population Council and others who attended a Technical Consultation in
Geneva in December 2003 to consider the evidence regarding married adolescent girls’ reproductive health,
vulnerability to HIV infection, social and economic disadvantage, and rights.
3
World Health Organization & United Nations Population Fund
Executive
summary
arriage is widely regarded as a
place of safety to shelter from
the risks of adolescence. In
many parts of the developing world, parents
and policy makers see marriage as a walled garden where cultural and family values protect
young girls from defilement and stigma.
Particularly in poorer and rural areas, there is
pressure on parents to marry off their daughters while they are very young before they
become an economic liability. Millions of girls
reluctantly enter into marriage while they are
still children, just sexually mature but unready
in every other way for this profound change in
their lives. Typically, an adolescent bride knows
little of her new husband or new life, has little
control over her destiny and is unaware of the
health risks that she faces.
When an adolescent girl starts a sexual relationship with a man 10 years older than she is,
he may be sexually experienced. If he is infected with a sexually transmitted infection (STI)
or with HIV, a marriage certificate offers no
protection. In the context of the AIDS pandemic, it is a chilling fact that the majority of
unprotected sex between an un-infected adolescent girl and an infected older man takes place
within marriage with the blessing of parents
and community. Neither AIDS nor STIs respect
marriage as a place of safety.
Early marriage below the age of 18, and particularly very early marriage below the age of
16, distorts the life pattern of young girls. It
often brings an end to their education and their
hopes of an independent income. It places a
young girl in a position of isolation, detached
from her own family and friends and living
within a household where she may not be val-
M
4
ued until she has proved her fertility.
The newly married couple must try to create
a life-long relationship under conditions where
they have little or no pre-existing knowledge of
each other, there is no sense of equality and
they have little support. They have unprotected
sex, under pressure for the young bride to conceive within the first year of marriage. If sex is
not freely given by the girl, it may be taken as a
right by the man.
In sub-Saharan Africa the risk of HIV infection is very high, and everywhere there is a risk
of sexually transmitted infection. Such infections may damage the fertility of a young
woman, and cause the stigma that early marriage was supposed to avoid.
An adolescent bride who becomes pregnant
receives new status as a mother-to-be, but also
faces new dangers. Pregnancy and delivery
carry increased risks for adolescent first time
mothers, who may be neither physically nor
psychologically ready for childbirth.
In the case of very young mothers risks may
arise from becoming pregnant before the body
is fully grown and prepared. In the case of older
adolescents, the risks are mainly those associated with a first pregnancy. The young mother
knows little about her own body or warning
signs, and lacks sufficient money and status in
her new household to access antenatal care or a
skilled attendant at the birth. There is unlikely
to be a system for her to receive obstetric care in
an emergency. These circumstances lead to
death in childbirth for too many young mothers, while for every girl who dies, another 30
suffer a pregnancy related illness, injury or disability. Some injuries cause a young married
girl to be abandoned by her husband and new
family and left with no means of support.
This picture of too early marriage is reflected
in South Asia, parts of sub-Saharan Africa, and
some parts of Western Asia1 and Latin America.
1. In line with current UN usage, this document uses Western Asia for what was previously referred to in English as the Middle East,
except when referring to data collected and cited as being for ‘the Middle East’.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Mothers who were unable to make choices for
themselves, are often under pressure to compel
their daughters to repeat the cycle.
Early marriage often takes away a girl's
human right to choose when to marry, to
choose her husband or to consent to sex. It prevents her from making informed choices about
protected sex based on an understanding of the
risks and the options.
Even when legislation protects girls from
early marriage and early childbirth, deep rooted cultural customs may slow the pace of
change. However, in many places there are programmes designed to delay marriage, to
encourage adolescent girls to stay in school and
to delay the birth of the first child. Programmes
also seek to ensure that young married girls
have a better chance of a healthy pregnancy, safe
delivery and good quality postnatal care. The
most promising programmes engage adolescent girls, parents, husbands and in-laws, as
well as social and cultural issues, so that the
rights of adolescent girls can be protected by
the societies in which they grow and develop.
The Millennium Development Goals for
international development cannot be achieved
without tackling early marriage. This document
explores these issues and outlines some promising programmes in countries where early marriage and early childbirth are common.
■
Millennium Development Goals
Tackling the ill-effects of early marriage has a direct bearing on six of the eight Millennium
Development Goals agreed in September 2000 as development priorities until 2015.
Goal 1: Eradicate extreme poverty and hunger
Young brides are less likely to have the training and opportunity to earn, and less likely to be
able to access resources.
Goal 2: Achieve universal primary education
Eliminating the worst examples of early marriage, below the age of 15, will allow girls to
complete primary education, and acquire skills to increase their chance to earn an income.
Goal 3: Promote gender equality and empower women
Giving adolescent girls a choice in whether to marry and providing alternatives to early
marriage will give girls greater self-confidence and choice. Girls who marry will have greater
confidence to control their own fertility, and to seek treatment for infections or when pregnant.
Goal 4: Reduce child mortality
Delaying first births and improving antenatal, delivery and postnatal care for young first time
mothers will have a significant impact on child mortality figures.
Goal 5: Improve maternal health
The target is to reduce by three-quarters the ratio of women dying in childbirth by 2015. Young
first time mothers have double the chance of dying during or after childbirth. Very young
mothers below the age of 15 have a five-fold chance of death.
Goal 6: Combat HIV/AIDS, malaria and other diseases
Adolescent girls who marry older men have a heightened risk of HIV. Reducing levels of
adolescent marriage is an essential part of an overall programme to reduce the risks of HIV.
5
World Health Organization & United Nations Population Fund
What do we
mean by
early marriage?
T
he UN Convention on the Rights of
the Child (CRC) marks the age of 18
as the dividing line between childhood and adulthood. However, the legal framework for marriage varies between countries
and can be different for males and females. In
some cultures, religion or tradition permit
marriage at the age of 12 or earlier.
The CRC promises children the right to education and the highest attainable standards of
health, and the right to be protected from mental and physical violence, sexual abuse and sexual exploitation. Children have the right to
have their views taken into account and not to
be separated from their parents against their
will. Anyone below the age of 18 is a child
“unless under the law applicable to the child,
majority is attained earlier”1. In some countries
marriage automatically confers adult status.
Girls who marry below the age of 18 can lose
the protection of the CRC.
International conventions have insisted for
more than 50 years that marriages should be
freely entered into. The Universal Declaration
of Human Rights says marriage shall only be
entered into “with the free and full consent of
the intending spouses”. However, the legal
framework in countries may lack sufficient
power to offer this protection. As an example,
in Ethiopia, the Civil Code says that consent
obtained by force for marriage is invalid.
However, the Code says that an agreement
based on 'reverential fear' for a parent does not
invalidate a marriage.2
The Committee that oversees the Convention
on the Elimination of All Forms of
6
The Convention on the Rights of the
Child (CRC) defines a child as anyone
under the age of 18. The World Health
Organization defines an adolescent as a
person aged 10-19.
Young people are defined as persons
aged 10-24, while youth are defined as
15-24-year-olds.
Discrimination against Women (CEDAW) has
recommended that 18 should be the minimum
legal age for marriage for both males and
females. However, 20 countries are not parties
to CEDAW and another 23 have made reservations, withholding support from Article 16
which guarantees equal rights in marriage.3
The legal age of marriage varies from 14 in
Bolivia to 21 in Cameroon. Traditional marriages are often allowed at ages well below the
legal age and there are still many marriages initiated as soon as the girl becomes sexually
mature as defined by the onset of menarche,
typically around 12 to 14 years of age. In
Ghana, young people below the age of 18 can
marry with the consent of a parent or guardian.
In Colombia, the legal age of marriage is 18 for
boys and girls, but boys over the age of 14 and
girls over the age of 12 can marry with the consent of their parents. Turkey has a legal age of
15 for girls and 17 for boys, but religious marriages can take place at younger ages.2
Variations in marriage
There are social and cultural variations in marriage. Marriage is not always one fixed event
and the processes are changing throughout the
developing world. Even within arranged marriages there is a huge variation in practice. A
girl may be betrothed at a very young age but
not live with her husband until later.4
1. Convention on the Rights of the Child, Article 1.
2. Haberland N et al. 2003. Married Adolescents an Overview, presented at WHO/UNFPA/ Population Council Technical Consultation on
Married Adolescents, Geneva.
3. Figures for accession and reservations are as at August 2005. The status of accession to CEDAW by individual countries can be
checked on the Office of the High Commissioner for Human Rights website. Go to http://www.unhchr.ch/ and click on Treaties.
4. Brady M. 2003. Differentiating risk perception and protection needs across the marital transition, presented at WHO/UNFPA/ Population
Council Technical Consultation on Married Adolescents, Geneva.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
"The betrothal and the marriage of a child
shall have no legal effect, and all necessary
action, including legislation, shall be taken to
specify a minimum age for marriage and to
make the registration of marriage in an official
registry compulsory."
Convention for the Elimination of All Forms of
Discrimination Against Women, Article 16.2.
Some engaged couples live together before
marriage. Other betrothed couples may ‘date’
before marriage and this may or may not
include sexual relations. In other societies premarital sex is strictly forbidden.
Couples who cohabit may consider themselves as married, even if no formal marriage
ceremony has taken place, and if asked for a
survey or census would give their status as married. In some cultures, couples may have a baby
together before marriage to demonstrate fertility. Other societies tolerate the taking of more
than one wife by a man, although studies have
found that women in polygamous unions
strongly disapprove.1
In some societies of Pakistan and South India
cousin marriage systems are used to strengthen
ties within families, and such marriage systems
can have complex rules.2 In other societies, for
example in north India, there are strict rules
preventing such marriages, and ‘exogenous’
marriages are arranged outside the family.
Combination of factors
Two factors can combine to raise concern over
the circumstances of adolescent brides. One is
the extreme young age at which marriage can
take place; the other is lack of choice and autonomy, especially on the part of the adolescent
girl, but also on the part of her husband.
The majority of adolescent brides in Gujurat
Married at 12 years of age
to a man who is older
than her own father
Maimuna was married at the age of 12 to a
man older than her father whom she had
never seen before their wedding. She is his
fourth wife and has three children. She is
lonely and desperate.
Maimuna says: “Forceful marriage brings
about hatred and once you hate someone,
you can do any evil act against him.”
She thanks God that only one of her children
is a girl. “I cannot give out my daughter for
marriage at 12. I will educate them if I have
the means.”
Source: Mario V Bello, Adolescent Health and Information
Project, Kano, Nigeria
and West Bengal, India, have not met their husbands before the marriage ceremony.3 This is
also true in a broader range of countries for
girls who are married below the age of 16. In
Egypt, girls are more likely to have a say whom
they marry if they have stayed longer in school,
have literate parents and have worked before
they marry.4
One study in Bangladesh found that almost
all girls who married between the ages of 13
and 19, and their husbands, would have preferred later marriage.5 Some had pursued this
with their parents but, in most cases, their
requests were ignored. A father's death, a large
number of daughters, and poor financial circumstances influenced family decisions to
marry off their daughters at an early age.
Where young girls are perceived as an economic liability, their marriage may form part of
a family's survival strategy. Families may even
agree to dowry demands from the husband's
1. UNFPA. 1999. Interactive Population Center. Sexual and reproductive self-determination. Voluntarism and marriage.
2. Cleland J. 2005. Correspondence.
3. Santhya K et al. 2003. The gendered experience of married adolescent girls in India: Baseline findings from the First-Time Parents Project,
presented at the Second Asia and Pacific Conference on Reproductive and Sexual Health, Bangkok.
4. El-Zanaty et al. 1996. Egypt Demographic and Health Survey 1995, National Population Council, Cairo.
5. Chowdhury S. 2003. Pregnancy and postpartum experience among first time young parents in Bangladesh; preliminary observations, in WHO
2003. Towards adulthood, Exploring the sexual and reproductive health of adolescents in South Asia, editors Bott S et al.
7
World Health Organization & United Nations Population Fund
family, which they cannot meet.1 A failure to
meet dowry promises affects the position of a
married girl within her new home, contributing to feelings of fear, shyness and shame.
Although early marriages are often said to
reflect traditional cultures, the pressures that
lead to early marriage are present-day. An
investigation in rural Jaipur by the Indian magazine, Frontline, found that poverty and rising
marriage costs were the main reasons given by
parents for early marriage and for marrying off
more than one daughter at a time.1 Custom
and tradition were hardly mentioned as reasons. The report concludes that insecurity and
rising expenses may be forcing mothers who
themselves married after the age of 18 to marry
off their daughters before they are 18.
Figure 1
Percentage of
adolescent girls
married by the
ages of 15 & 18
The proportion of girls
married by 15 and 18
years was highest in
Asia, followed by West
Africa, South and East
Africa and Western
Asia (Middle East)
In this document, most data is based on studies or surveys in which adolescent girls or
women are asked about their own experience of
marriage. Marriage is therefore largely selfdefined, and may be formal or informal.
It should be acknowledged that many older
adolescents freely choose to enter into cohabitation or marriage, and that many see it as a
positive experience which releases them from
the lack of autonomy, choices and access to
services such as contraception, that can go
along with being an unmarried adolescent. The
main focus of concern in this document is on
marriage at a very young age, on lack of autonomy and freedom to choose by adolescent girls,
and on the risks this brings to their health and
life chances.
■
70
Age 15
60
Age 18
50
40
30
20
10
%0
South & East
Africa
West Africa
Latin Am erica
& Caribbean
Asia
Western Asia
(Middle East)
Source: DHS data. Calculated from surveys of women aged 25-49. Cited in Bruce J and Clark S. 2003.
Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy, presented at
WHO/UNFPA/Population Council technical consultation on married adolescents, Geneva.
8
1. Frontline. 2005. Child Brides: Reluctant to Act. Vol 22, Issue 14, July 02-15, 2005.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Early marriage
declining — but
still far to go
T
he age of marriage is rising in most
parts of the world, but the number of
early marriages is still substantial.
Traditional or religious tolerance of early marriage can slow the trend to later marriage. Over
the next ten years an estimated 100 million girls
will marry before their 18th birthday. They represent one third of adolescent girls in developing countries excluding China.1
◆ 60% or more of girls are married by 18 in
Burkina Faso, Chad and Bangladesh,2
◆ 50% or more of girls are married by 18 in
Mozambique and Nepal,
◆ 40% or more of girls are married by 18 in
Nigeria, Ethiopia, Malawi, India and the
Yemen,
◆ 30% or more of girls are married by 18 in
Ghana, United Republic of Tanzania,
Guatemala and Indonesia,
◆ 20% or more of girls are married by 18 in
Zimbabwe, Brazil, Haiti and Egypt.
International
Planned
Parenthood
Federation (IPPF) data from 55 countries
shows that, between 1992 and 2001, the legal
age of marriage was raised in 23 countries for
women and in 20 countries for men.3
The largest falls in early marriage have been
seen in West Africa, East and Southern Africa,
South and South-East Asia and Western Asia
(Middle East). There were smaller decreases in
East Asia and in Central America and the
Caribbean. When cohabitation is included
there were small increases in South America
and in the former Soviet Union.
In some countries the decline has been rapid.
In Bangladesh the percentage of girls married
by 18 years fell from almost 90% to 65% in 20
years. In Ethiopia it fell from 79% to 49%, in
Nepal from 70% to 55% and in Nigeria from
55% to 40%. There were marginal decreases in
Burkina Faso, Mali and the Dominican
Republic.3
However, very early marriage is still common.
The median age of marriage is 16.7 in Mali and
Figure 2
Women married by the age of 18
Comparing the histories of women in their 40s and women in their 20s shows a long-term decline in early marriage.
Form er Soviet Asia
South and South-East Asia
West and Middle Africa
East and Southern Africa
Source: Mensch B.
2003. Trends in
the Timing of
First Marriage
Data Source: DHS
from 51 countries
1990-2001
Western Asia (Middle East)
40-44 year olds
Caribbean/ Central Am erica
20-24 year olds
South Am erica
%
0
10
20
30
40
50
60
70
1. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy, presented at WHO/UNFPA/
Population Council Technical Consultation on Married Adolescents, Geneva.
2. Figures from Haberland et al. 2003. Married Adolescents: An Overview, presented at WHO/UNFPA/ Population Council Technical
Consultation on Married Adolescents, Geneva.
3. Mensch B. 2003. Trends in the Timing of Marriage. Analysis conducted for the National Academy of Sciences Report on Transitions to
Adulthood in Developing Countries.
9
World Health Organization & United Nations Population Fund
Early marriage
10
Nepal: education ends when a
girl marries young
● Early marriage is declining
but the number of girls married
by the age of 18 is still large.
● Girls in rural areas and
those who leave school early
are the most likely to be
married early.
● Many countries have laws to
prevent early marriage. This
does not always prevent many
girls becoming married as soon
as they are sexually mature.
30 years ago, marriage under the age of ten
was common in Nepal. The legal age for
marriage was raised and by 1991 the mean
age of marriage had risen to 18.1 years.
According to the 1996 Nepal Family Health
Survey (NHFS), 44% of female adolescents
were married and, of these, more than half
were already mothers or pregnant.
32% of women who dropped out of school
cited marriage as the reason. The NFHS also
showed that 32% of illiterate adolescents had
started childbearing, compared with only 10%
of those who had gone on to secondary
education.
16.1 in Bangladesh.1 In Amhara, Ethiopia, half
of women aged 20-24 were married by the age
of 15, and the figures were 38% in Bangladesh
and 25% in Jinotega, Nicaragua.1
◆ Boys are much less likely than girls to marry
early. The highest rate of early marriage for
young men is in Chad where about a quarter
are married by their 20th birthday: 85% of
girls in Chad are married by this age.1
◆ There are large differences between urban
and rural populations. In South and SouthEast Asia twice as many rural girls marry by
the age of 18 compared with urban girls. In
Mali 74% of rural girls are married by the age
of 18, but only 46% of urban girls.1
◆ There is a strong correlation between early
marriage and leaving school. In West and Mid
Africa, 70% of girls with three years of
schooling or less marry by the age of 18.2 For
girls with eight or more years of schooling
this figure falls to 12%. The same trend is
seen to a lesser extent in every region, with
early marriage declining in girls who have
had four or more years of education, and
declining further in girls with eight or more
years of education.2 In Brazil, Kenya and
Mozambique, married girls with no children
are even more likely than unmarried mothers
to leave school.1
◆ Conflict can disrupt trends and patterns in
marriage. In Rwanda and Burundi the usual
age of marriage was about 25 for women.
Following the war the age of marriage fell.3
In conflicts it can be safer for an adolescent to
be married as she may receive more protection. However, conflicts have also made men
less able to pay bride price, leading them to
delay marriage.
■
Adhikari R. 2003. Early Marriage and Childbearing:
Risks and Consequences published in WHO.
2003. Towards Adulthood, Exploring the Sexual
and Reproductive Health of Adolescents in South
Asia, editors Bott et al.
1. Figures from Haberland et al. 2003. Married Adolescents: An Overview, presented at WHO/UNFPA/ Population Council Technical
Consultation on Married Adolescents, Geneva.
2. Mensch B. 2003. Trends in the Timing of Marriage. Analysis conducted for the National Academy of Sciences Report on Transitions to
Adulthood in Developing Countries. Data Source. DHS tabulations.
3. WHO Regional Office for Africa. 2003. Contribution at WHO/UNFPA/ Population Council Technical Consultation on Married
Adolescents, Geneva.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Sexuality and
health in early
marriage
T
he isolation of young adolescent girls
within marriage and their lack of
education means that they are often
the least well-informed group of young people
about sexual and health issues.
In Bangladesh only a third of married girls in
one study described themselves as well
informed about sex before marriage.1 In
Northern Nigeria, another area with high rates
of early marriage, married girls had about the
same level of knowledge about fertility and
contraception as unmarried girls, but knew significantly less about AIDS and RTIs. Fewer than
half of the married girls in Northern Nigeria
had heard of AIDS and only a quarter knew
that they could get HIV through having sex
with an infected man. Even those who had
heard of AIDS seemed unconcerned. More than
60% felt that they were at no risk of AIDS.2
In Kenya younger married girls were less
knowledgeable than older married girls about
fertility, STIs and HIV. Younger married girls
had significantly less knowledge about their fertile period, and were less likely to know that
they could conceive even if the man withdrew
before ejaculation.3
In Nepal a survey of 2000 households showed
that young married women had access to the
radio but less access than their unmarried peers
to television or written information. They had
the lowest level of awareness amongst young
people about STIs, and only two thirds had
heard of HIV/AIDS (as opposed to 95% of
males and single females). Almost half of mar-
Isolated and less
aware
● Married girls often lack
knowledge about sex and the
risks of STIs and HIV/AIDS.
● Younger wives may feel
confused, ashamed or isolated.
ried girls knew that if a husband and wife are
mutually faithful that is protective against HIV,
and that they are at risk if a husband frequents
sex workers. However, married girls were much
less likely than unmarried girls to know that
condoms can prevent the transmission of sexual infections as well as pregnancy.4
Many urban married women in India recall
their first sexual experience within marriage as
a time of confusion and shame.5 Women who
had married before the age of puberty often felt
they had been 'tricked' into sex by an older
woman in her husband's family. Others
described shyness and modesty ('sharam'), in
circumstances where they were having their
first sexual experience in the house of a
stranger, where other members of the family
were encouraging the couple to be sexually
active. Others felt that they had been forced
into sex without knowing exactly what it
entailed. Others saw sex within marriage as part
of a pragmatic arrangement.
Isolation and lack of awareness of their rights
means that married adolescents may be more
willing than older women to put up with gender violence within the marriage. Married girls
are slightly more likely to say that it is acceptable for a man to beat his wife or to force a
woman to have sex. There is some evidence that
gender violence is more likely with younger
1. Khan M, Townsend J and D’Costa S. 2002. Behind closed doors: a qualitiative study of sexual behaviour of married women in Bangladesh.
Culture, Health and Sexuality, 4(2), April-June 2002.
2. Haberland N, et al. 2003. Married Adolescents: An Overview, presented at WHO/UNFPA/ Population Council Technical Consultation on
Married Adolescents, Geneva.
3. Erulkar A and Onoka C. 2003, Data from Adolescent Reproductive Health Information and Services Survey, Central Province, Kenya, 2001.
4. Neupane S, Nichols D and Thapa S. 2003. Knowledge and Beliefs about HIV/AIDS among Youth in Urban Nepal. Asia-Pacific Population
Journal, Dec 2003.
5. George A. 2003. Newly married adolescent women: experiences from case studies in urban India, published in WHO. 2003. Towards adulthood,
exploring the sexual and reproductive health of adolescents in South Asia, edited Bott S. et al.
11
World Health Organization & United Nations Population Fund
wives. A DHS survey in Egypt found that 29% of
married adolescents had been beaten by their
husbands.1 In Bangladesh married men under
the age of 30 were more likely than older men to
beat their wives.2 The age difference between
husband and wife within marriage suggests that
younger wives are therefore more likely to be
beaten. A study in China, Province of Taiwan also
showed that girls under the age of 18 were more
likely to experience domestic violence.2
"Efforts must be made to narrow the
information gaps that exist between the
sexes and marital status. Married females
remain largely neglected. … Current
approaches to information and knowledge
dissemination do not seem to be sufficiently
gender or marital-status sensitive."
Asia-Pacific Population Journal. 2003. Knowledge and Beliefs
about HIV/AIDS among Youth in Urban Nepal.
Age gap can lead to isolation for younger wives
The age gap between an adolescent bride and her husband tends to be bigger, the younger
the adolescent girl. The mean age difference between a married girl aged 15-19 and her
husband is 13.9 years in Guinea, 10.7 years in Burkina Faso, and 9.8 years in Bangladesh.1
Age gaps tend to be smaller in Latin America and the Caribbean, but are greater than seven
years in Haiti and the Dominican Republic. As the age of marriage increases, the age
difference between a young bride and her spouse decreases.2
This age gap shapes the social context of the marriage. The greater the gap the less easy it
is for the couple to talk. In Mali, a married girl under the age of 19 is twice as likely to discuss
how to avoid AIDS with her husband if he is less than six years older than she is.3
The young married girl is consistently more isolated than an unmarried girl or older married
woman. In Bangladesh, 80% of unmarried girls reported having many friends who lived close
by while only just over 40% of married adolescents could say the same.4
In an Indian study only one in seven married girls aged 15-19 (13.8%) could go to market
without her husband's permission and only one in ten (10.2%) could visit friends without
permission.5 Twice as many older married women had the freedom to do these things. The
age gap can also be a risk factor for STIs and HIV/AIDS. Among girls aged 15-19 in Uganda,
the risk of HIV infection doubles for those whose partners are ten years or more older than
they are.6 In Zimbabwe, the risk increases for each year of age difference between partners.7
1. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy, presented at
WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.
2. Mensch B. 2003. Early Marriage in a Demographic Context, presented at WHO/UNFPA/ Population Council Technical Consultation
on Married Adolescents, Geneva.
3. DHS data, Mali.
4. Amin S, Mahmud S and Huq L. 2002. Baseline Survey Report on Rural Adolescents in Bangladesh. Dhaka: Ministry of Women’s
Affairs, Government of Bangladesh.
5. Santhya K and Jejeebhoy S. 2003. Sexual and Reproductive Health Needs of Married Adolescent Girls. Economic and Political Weekly
Vol XXXVIII, No 41.
6. Kelly R and Gray R, 2003. Age Differences in Sexual Partners and Risk of HIV-1 Infection in Rural Uganda. Journal of Acquired Immune
Deficiency Syndromes,Vol 32, No 4, April 1, 2003;
7. Gregson S et al. 2002. Sexual Mixing Patterns and sex-Differentials in Teenage Exposure to HIV infection in Rural Zimbabwe, The Lancet,
359 1986-2003, (6&7 both cited in Luke N and Kurz K. 2002. Cross-generational and Transactional Sexual Relations in Sub-Saharan
Africa: Prevalence of Behavior and Implications for Negotiating Safer Sexual Practices ICRW AIDSMark.)
12
1. Bruce J. cited in UNICEF. 2001. Early Marriage, Child Spouses. Innocenti Digest, No.7. Florence, Italy: Innocenti Research Centre.
2. Nurse J. 2003. Gender Based Violence in Married and Partnered Adolescents. presented at WHO/UNFPA/ Population Council Technical
Consultation on Married Adolescents, Geneva.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Secret hopes of the invisible married adolescents
In Senegal one in nine girls is married by the age of 15 and half are married by the age of 20.
However, married girls of this age were not recorded as adolescents in a household survey in
Dakar. Married girls, even those who marry at 15, are treated as adult women and known as
Sokhna or Diongoma. Words in the Wolof language for adolescent — Ndiankhe and
Ndiangamar — connote frivolity.
A Population Council research team conducted a qualitative study to find out about these
invisible married adolescents. Some had been married as early as 12 and some were on their
second marriage or in polygamous unions. In most cases parents had arranged the marriage.
Some girls had not met their spouses before marriage, and a few had learned they were to be
married only on the day of the wedding,
The Senegal HIV/AIDS national programme identified married adolescents as a sub group at
high risk of HIV/AIDS because families tended to marry them to older migrant workers.
However, married adolescents perceive themselves as being at low risk of HIV and their
families share this view.
Only 6% of married girls continued in school. Most dropped out because their husbands or
parents asked them to do so. However, many would like to continue to learn, and about a
third made an agreement with their husbands that they could continue in school.
They lamented how little they knew about their bodies, sex and reproductive health. They
wanted to learn to read and write and wanted skills that would allow them to earn. Married
adolescents are financially dependent on their husbands. They do more work and enjoy less
freedom after marriage.
The girls' families expect a child soon after marriage, but girls prefer to delay. Girls under 15
wanted to delay childbirth 4-5 years; those aged 15-18 for 2-3 years.
Source: Diop N and Meyers C. 2003. Married Adolescent Girls’ Lives: A Perspective from Senegal. Population Council. Data DHS 1997.
In Brazil a quarter of men in one study had
physically abused their partners. Rates of violence were highest in the 20-24 age group
whose partners were more likely to be adolescent girls.1
Some very young brides have little or no say
in their sexual initiation. A 1997 study in
Calcutta found that 80% of girls who married
before the age of 15 and who attempted to resist
sex with their husband, were forced to do so
against their will.2 In many countries rape laws
exclude forced or violent sex within marriage.
Bruce and Clark show that in many countries
women are conditioned to accept that a hus-
band has a right to sex.3 Asked whether a husband was justified in beating his wife if she
refused him sex, more than 40% of women
agreed in Ethiopia and Zambia and more than
60% agreed in Mali. In Turkey, 13% of women
agreed and in Haiti, more than 10% agreed.
In a survey by the Navrongo Health Research
Centre, Ghana, of 3,220 adolescent girls, one
third agreed that a man sometimes has to force
a girl to have sex, and 38% agreed that a boy is
sometimes justified in beating his girlfriend.
Married adolescents, made up only 15% of this
sample, but were slightly more likely to accept
and justify male violence against women.4 ■
1. Instituto PROMUNDO and Instituto NOOS. 2003. Men, gender-based violence and sexual and reproductive health: A study with men in Rio de
Janeiro, Brazil.
2. UNICEF. 2001. Early Marriage, Child Spouses. Innocenti Digest, No.7. Florence, Italy: Innocenti Research Centre.
3. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy. Table 5.
4. Debpuur C. 2003. Married Adolescents in the Kassena-Nankana District, presented at WHO/UNFPA/ Population Council Technical
Consultation on Married Adolescents, Geneva.
13
World Health Organization & United Nations Population Fund
Early marriage
often leads
to unsafe sex
M
arriage is often seen as a state
where women are protected
against sexually transmitted
infections and against HIV/AIDS, but it is not.
A monogamous marriage between two uninfected people is indeed protective. But marriage
can also institutionalise the transfer of infection
and allow society to drop its guard. The idea of
marriage as a fortress against HIV is a myth.
The most common route to risky sexual
intercourse for adolescent girls in developing
countries is through marriage. This is because,
in most countries, more married adolescent
girls than unmarried adolescent girls are having
unprotected sex, they have sex more frequently
and they are less likely to protect themselves. In
many countries the use of condoms is almost
exclusively confined to non-married sexual
relationships.1 In this context, marriage can
include stable relationships that have not been
formalised. In the Dominican Republic, 22.4%
of 15-19-year-old girls in 1996 considered
themselves to be married, even though the vast
majority of marriages at this age are ‘without
papers’.2 Of sexually active girls in this age
group, 87% were married and only 1.5% of
married girls used a condom the last time they
had sex.
In many cultures, parents encourage their
daughters to marry young because they regard
marriage as a place of safety that will protect
them from harm and disgrace. In fact, married
adolescent girls tend to have higher rates of
HIV than their sexually active unmarried counterparts. Young married women have little
knowledge of the risks of sex or what they can
14
No hiding place
● Marriage is no protection
against STIs, HIV and AIDS.
● Most unprotected sex by
adolescent girls takes place
inside marriage.
● Young girls are often married
to sexually experienced older
men who may be infected.
● Condoms are used less within
marriage than outside marriage.
“Almost magically, the same partner who prior
to marriage may have been viewed as 'risky',
upon marriage becomes safe; sex within
marriage is often assumed to be safe.
Changing perceptions of risk and bringing
condoms across the marital boundary is an
important programmatic challenge.”
Martha Brady. Differentiating risk perception and
protection needs across the marital transition.
do to protect themselves. They are relatively
powerless within the marriage to decide on
issues of contraception and protection. They
are encouraged, and often desire, to have a baby
as soon as possible to prove their fertility, and
are therefore unlikely to use contraception.
Even where a girl plans to delay pregnancy, she
may use contraception which is not protective
against STIs or HIV. In many cultures condoms
are "de la calle" (for the street), that is for sexual relationships considered risky, not "de la
casa" (for the home) where sex is considered
safe. In Asia, Africa, Latin America and the
Caribbean, condoms are mainly reserved for
short-term sexual relationships.
Bruce and Clark looked at DHS data from 26
countries in Africa, Latin America and the
1. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy, presented at WHO/UNFPA/
Population Council Technical Consultation on Married Adolescents, Geneva.
2. Goldberg R. Early marriage and HIV in the Dominican Republic, presented at WHO/UNFPA/ Population Council Technical Consultation
on Married Adolescents, Geneva.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Caribbean and found that “in most of the 26
countries with data on sexual activity on married and unmarried adolescents the majority of
sexually active girls aged 15-19 are married”.1
In another five countries (Bangladesh, Egypt,
India, Indonesia and Turkey) “we can plausibly
assume that more than 80% of sexually active
girls are married”.1 Figure 3 shows that a clear
majority of sexually active girls who had unprotected sex ‘last week’ were married.
Not only are the majority of adolescents girls
who are having sex, married, but Bruce and
Clark found that the risk exposure of married
adolescents is even higher than these figures
suggest, because a married girl is likely to have
sex with her husband more frequently than an
unmarried sexually active girl has with her
boyfriend, and because sex within marriage is
much less likely to be protected with condoms.
Bruce and Clark conclude: “On average across
these 31 countries, 80% of unprotected sexual
encounters among adolescent girls occurred
within marriage”. 1
Figure 3:
Abstinence ‘not an option’
“In Mozambique, the overall HIV infection rate
amongst girls and young women — 15% — is
twice that of the boys their age, not because
the girls are promiscuous but because nearly
three in five are married by the age of 18, 40
per cent of them to much older, sexually
experienced men, who may expose their
wives to HIV and sexually transmitted
diseases. Similar patterns are common in
other nations where HIV is rapidly spreading.
Abstinence is not an option for these child
brides. Those who try to negotiate condom
use commonly face violence or rejection. And
in heterosexual sex, girls and women are
biologically more vulnerable to infection than
are boys and men … Parents know little about
sexuality, contraception or sexually
transmitted diseases, and many believe that
early marriage will 'protect' their daughters."
Dr Pascoal Mocumbi, Prime Minister of Mozambique.
2001. A Time for Frankness on AIDS and Africa, New York
Times, June 20, 2001
Percentage of married girls and of sexually active unmarried girls in selected countries
who said that they had had unprotected sex in the previous week.
100
90
Married
80
Unmarried
70
60
50
40
30
20
10
%0
Ethiopia
M alawi
Rwanda
Zambia
Benin
Cameroon
Ghana
M ali
Brazil
Dominican
Republic
Haiti
Nicaragua
Peru
DHS data, selected countries. Figure produced from data presented by Bruce J and Clark S (See footnote 1).
1. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy, presented at WHO/UNFPA/
Population Council Technical Consultation on Married Adolescents, Geneva.
15
World Health Organization & United Nations Population Fund
The risk of HIV or STIs comes not only as a
result of a husband’s sexual experience before
marriage, but also because of extra-marital sex.
In the Dominican Republic, where AIDS is the
leading cause of death for women of reproductive age, a study showed that 30% of married
men had had extra-marital sex in the previous
12 months and that the figures were even higher for younger men, who are more likely to have
younger wives.1 This researcher expressed the
view that: “It is normal for men to enter into
and maintain sexual relations with any number
of secondary partners, ranging from sex workers to secondary 'spouses' with whom they
form secondary family units, at times with children.”1
The relative risk of HIV within marriage is
increasingly reflected in statistics.
◆ A study in Kenya and Zambia, found that
infection rates amongst married girls aged
15-19 were 10 percentiles higher than among
unmarried girls the same age.2
◆ In India, infection rates are rising fastest
among married women, who accounted for
40% of all new infection cases in 2002.3
◆ The National AIDS report for Ethiopia for
2002 noted that infection rates had risen
amongst 15-19 year old females, attributing
this to "earlier sexual activity among females
and the fact that they have older partners".4 A
quarter of adolescent girls in Ethiopia are
married, and they represent 94% of girls who
are sexually active.
◆ In Kisumu, Kenya, almost one in three husbands of married adolescent girls is infected
with HIV, compared with only one in ten
partners of sexually active unmarried girls.5
16
Reality of forced sex replaced
dreams of school for Rakiya
Rakiya dreamed about going to school but
never saw the inside of a classroom. She was
married aged 12 years to man she hardly
knew. She was raped within her marriage and
lived in fear of the nights. Her father beat her
when she ran away.
Rakiya was still 12 when she had her first
child, a long, terrifying experience. She had
five children by the age of 20 and another on
the way, when her husband died.
With no source of income she was recruited
to the sex trade in Jeddeh. Now she sells
bean cakes by the roadside and earns
enough to feed her children and send her
boys to school.
Rayika believes that early marriage is due to
ignorance amongst parents. “They believe
that the girls will spoil, not knowing that is
wrong. I never fooled around with men until I
found myself in a terrible situation and I had to
use what God has given me to feed my
children.”
Source: Bello M. 2003. presentation at
WHO/UNFPA/Population Council technical consultation
on married adolescents, Geneva.
In Ndola, Zambia, twice as many husbands of
married adolescents are infected with HIV
compared with boyfriends of unmarried adolescents.5
◆ In the Rakai district of Uganda, 88.5% of girls
aged 15-19 infected with HIV were married,
while only 66.4% of uninfected adolescent
girls were married.6 Researchers commented, "This suggests that many of the HIV-positive female adolescents were infected by an
older husband."
■
1. Goldberg R. Early marriage and HIV in the Dominican Republic, presented at WHO/UNFPA/ Population Council Technical Consultation
on Married Adolescents, Geneva.
2. Glynn J et al. for the Study Group on Heterogeneity of HIV Epidemics in African Cities. 2001. Why do young women have a much higher
prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia. AIDS 15(suppl 4), S51-60. Cited in Bruce and Clark (op cit)
3. Center for Health and Gender Equity & Sexuality Information and Education Council of the United States. 2004. Women and
HIV/AIDS in the U.S. Global AIDS Strategy.
4. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy, presented at WHO/UNFPA/
Population Council Technical Consultation on Married Adolescents, Geneva.
5. Clark S. 2004. Early marriage and HIV Risks in Sub-Saharan Africa. Studies in Family Planning, September 2004.
6. Kelly RJ, et al. Age difference in sexual partners and risk of HIV-1 infection in rural Uganda. JAIDS 2003; 32(4): 446-451.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Early marriage
may be driven
by fear
E
arly marriage tends to be high in
poorer countries, in rural areas and
amongst girls who have less than six
years of education. But surveys show that most
adolescent girls would like to delay marriage
and childbirth — even if only for a year or two.
Few families want early marriage. Families
negotiate and arrange marriages because of
economic reasons or because they fear that
shame could be brought onto the family. The
main driving force behind early marriage is fear
of the alternative.
Historically, early marriage was desirable
because it increased the number of children
that a woman could have over a lifetime, but
today women want fewer children and want
them to be better spaced.1 Early arranged marriages today are more to do with family fears
that a girl's marriageable status may be ruined
in a society where there are few viable alternatives. Mothers may be committed to their
daughters having more opportunities and a less
restricted life than they themselves have had.
However, they also wish to protect the family
honour. Menarche is a warning bell for adolescent girls, and may mark the end of youthful
freedoms, while adolescence is a period of
experimentation for young men.
Families consider alternatives for their adolescent daughters only if they do not damage
marriage prospects. When asked what would be
the effect, if her daughter delayed marriage for
four years, one mother from Egypt replied: "I
would be worried for four more years."2 A
proverb in Nepal: “Spilled water on the
doorstep is very dangerous: anything can hap-
Daughter’s reputation may be
damaged
“In Nepal everyone wants the age of marriage
to be later but parents are worried that their
daughter will be harassed and that young
men will want to have sex, and her reputation
can be damaged even without having sex.”
Anju Malhotra, Director Population and Social
Transitions, International Center for Research on Women
Variations in the Meanings of Marriage: A Historical and
Cultural Perspective
pen,” alludes to the threat that a daughter kept
at home becomes an invitation to disaster.3
There may be economic disincentives for a
family to invest in a daughter's education since
a daughter traditionally becomes part of her
husband's household. There may also be a disincentive to encourage her to delay marriage.
Dowry is common in South Asia, Western
Asia and in Africa, where it is known as
‘bridewealth’. There are many variations and
the way that dowry works is changing.
Traditionally, dowry was a bequest, which a
bride takes into her marriage. In some settings,
it has been ‘modernized’ and is now a price in
cash or kind paid to the groom or his family. It
has also, in some settings, become more institutionalized and burdensome.
In rural
Maharashtra dowry was seen as optional in the
mid-1970s but by 1987, a bride could suffer if
dowry was not given. 4
This can lead to a tendency to see a daughter
as a commodity whose value is damaged by
delay. Young age can be seen as a guarantee of
virginity and husbands may pay a higher brideprice. In arranging early marriage, a family may
see itself as protecting a girl's virtue, prospects
and value, and the family income.
Dowry and brideprice have a long-term effect
on a relationship within marriage. In India, disputes over dowry and failures by the bride's
1. Malhotra A. 2003. Variations in the Meaning of Marriage: Historical and Cultural Perspective. ICRW. Presented at WHO/UNFPA/ Population
Council Technical Consultation on Married Adolescents, Geneva.
2. Mensch B. 2003. Trends in the Timing of First Marriage. Analysis for the National Academy of Sciences Report on Transitions in
Adulthood in Developing Countries.
3. Waszak et al. 2003. The influence of gender norms on the reproductive health of adolescents in Nepal - perspectives of youth. Published in WHO
2003. Towards adulthood Exploring the sexual and reproductive health of adolescents in South Asia, edited Bott S et al.
4. Vlasssoff C. 1994. From Rags to Riches: The Impact of Rural Development on Women’s Status in an Indian Village. World Development, Vol 22,
No 5, cited in Haberland N et al. 2003. Married Adolescents: An Overview.
17
World Health Organization & United Nations Population Fund
family to pay what they have promised are common reasons for a woman being beaten by her
husband.1 A groom who has paid a bride price
may regard his wife as his property. Asked
whether she could refuse sex with her husband
and whether he could beat her, a woman in
Ghana replied: "He has paid the bridewealth of
three cows to my father. That is why he has
absolute authority over me and my children."2
In some societies girls are not expected to be
virgins at marriage. In some African societies a
girl who demonstrates fertility by becoming
pregnant before marriage may enhance her
prospects of marriage. She may therefore feel
under pressure to 'prove she is a woman'.
What do men want from marriage?
There is little evidence about what most men
think about marrying young girls. In some settings men also have limited choices about
whom they marry.
Researchers in India found that although
adolescent males have more freedom than girls,
the two most important decisions in their lives
— choice of work and partner in marriage —
are largely decided by other adults.3 Male university students aged 24-31 years in Kaduna,
Nigeria, had postponed marriage so they could
finish their studies, but many were coming
under pressure from families. One said: "You
have to get a girl pregnant before you are married to prove that you are a man. You prove
yourself to your family by how many children
you have, You know, your mother will say that
she wants to have grandchildren."3
Boys can come under pressure to have early
sexual experience. Boys in Guinea reported that
if they did not have sex their reputations would
suffer among their male peers.3 Boys may see
paid work as validating their existence and giv-
18
Girls would prefer
to delay marriage
● Families may endorse early
marriage because they fear for
their daughter’s prospects, or
that delay will lead to disgrace.
● Most adolescent girls prefer
to delay both marriage and
childbirth.
● Adolescent males have more
autonomy, but may lack the
right to choose their wife.
● In many countries boys are
under social pressure to seek
early sexual experience.
ing them an income to sustain a family. Having
no work means having low status with family
and potential girlfriends. It has been suggested
in Jamaica that one reason for some girls delaying marriage is that they see few young men as
potential husbands. These examples show a
wide range of outcomes resulting from social
pressures on adolescent girls and boys.
Early marriage declines where there
are safe alternatives
Early marriage declines if there are viable and
safe alternatives for girls. Education and training leading to paid employment are two reasons
why girls may postpone marriage. In
Bangladesh and China, Province of Taiwan,
daughters and parents show interest in delaying
marriage, where jobs are available.4
■
1. Rao V. 1997. Wife-Beating in Rural South India: A Qualitative and Econometric Analysis. Social Science and Medicine, Vol 44, No 8, cited in
Haberland N et al. 2003. Married Adolescents: An Overview.
2. Adongo et al. 1997. Cultural Factors Constraining the Introduction of Family Planning Among the Kassena-Nankana of Northern Ghana. Social
Science and Medicine, Vol 45, No 12, cited in Haberland N et al. 2003. Married Adolescents: An Overview.
3. Barker G. 2003. Reflections on the Roles, Responsibilities, and Realities of Married Adolescent Males and Adolescent Fathers, presented at
WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.
4. Mathur S, Greene M and Malhotra A. 2003. Too Young to Wed: The Lives, Rights and Health of Young Married Girls. International Center for
Research on Women, citing Amin S et al. 1998. Transition to adulthood of female garment-factory workers in Bangladesh. Studies in Family
Planning 29(2): 185-200.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Gap between
marriage and
first child is
falling
A
lthough the average age of marriage is rising in most parts of the
world, the gap between marriage
and having a first baby is decreasing and this
offsets some of the benefit of delaying marriage1. There is a double pressure on a young
bride to conceive within a year: a rise in status
for a young wife who gives birth, but gossip and
disapproval if too much time passes before she
proves her fertility.
Young couples often have their first child
within 12-20 months of marriage, and while
older adolescents are more likely to become
pregnant quickly, some of the youngest girls
also become mothers at a very young age.
In Bahrain one in five adolescent girls who
Girls under pressure
to have first baby
● The delay between getting
married and having a first child
has fallen over a 20-year period.
● Many married adolescent girls
and their husbands would prefer
to delay their first baby.
● Young married couples find it
difficult to put their wishes into
effect.
● They fear that delay will lead
to gossip and damage the status
of a married adolescent.
gives birth does so before the age of 16, and
some child mothers are as young as 11.
In Mali, where 25% of women are married by
Grandmother at 24, great grandmother at 38
Sitting on the floor of her dishevelled home the size of a broom cupboard in Old Delhi, Bano
recounts her precocious achievements. She was married at the age of 10, and had her first
child when she was 11. Her daughter was 12 when she married and 13 when she had her
own first child, making Bano a grandmother at 24.
Bano's granddaughter also married at puberty, and gave birth when she was 14 — thus Bano
became a great grandmother at 38.
In another room across a narrow, dank, vertiginous staircase crawling with toddlers and
goats, lives Bano's neighbour 16-year-old Rukshana, mother of three children. Her younger
sister Yasmin is 13. She will be getting married any day now. In virtually every house in this
Muslim neighbourhood it's the same story.
“I had no idea the minimum age for marriage in India is 18. All our girls are married the
moment their periods start,” says Bano, who, like many child brides who bear children early
and frequently, looks 70, although she is 48."
Amrit Dhillon, A mum at 11, a great grandmother at 38, The Times (London) 28 August 2002.
1. Mensch, B. 2003. Trends in the Timing of First Marriage Analysis conducted for the National Academy of Sciences Report on Transitions
to Adulthood in Developing Countries. Much of the data in this section is from this source.
19
World Health Organization & United Nations Population Fund
the age of 15, one in ten adolescent girls has
been pregnant by the age of 15, and nearly 40%
are pregnant or have already had a child by the
age of 17.1
The 1996 Nepal Family Health Survey
(NFHS) showed that 44% of female adolescents
were married, and that more than half (54.3%)
of the married adolescents girls were already
mothers or were pregnant.2 Other data shows
that in Bangladesh, Cameroon, Malawi, Mali,
Niger and Nigeria 8%-15% of adolescents were
aged 15 or less when they gave birth.3
Figure 4 shows that the gap between getting
married and having a baby has fallen over a 20
year period in most parts of the developing
world. This was assessed by asking women who
had been adolescent brides, but were at the time
of interview aged 40-44 years or 20-24 years
about their experiences.
Figure 4 shows that the older age group of
women in South and South-East Asia, West and
Central Africa and Western Asia (Middle East),
had delayed their first babies for an average of
30 months. In Central and South America, in
the Caribbean and in East and Southern Africa,
this older age group had delayed childbirth for
more than 20 months.
Figure 4:
‘My in-laws wanted me to
have a child’
"I do not feel any pleasure about this
pregnancy. I did not expect to conceive this
early as I think I am too young to bear
children. This will increase my responsibilities.
I will have to look after the children at such a
young age. But my in-laws wanted me to
have a child."
17 year old wife in rural Maharashtra, India
Source: Alka Barua et al Caring Men? 2004. Husbands'
Involvement in the Maternal Care of their Young Wives,
Economic and Political Weekly December 25, 2004
However, in the case of women who had been
adolescent wives more recently and were in
their 20s when questioned, the average delay
had fallen to less than 20 months almost everywhere, and to just over 20 months in South and
South-East Asia and in West and Central Africa.
The largest decline in waiting time occurred in
Western Asia (Middle East), West and Central
Africa and South and South-East Asia.
This comparison between the two groups
shows that the delay in having a first child is
falling. This change offsets some of the gains in
the decline in early marriage over this 20-year
Average number of months between marriage and first birth:
Women now aged 40-44 and 20-24 who married as adolescents.
40-44 year olds
South Am erica
20-24 year olds
Caribbean/Central Am erica
Western Asia (Middle East)
East/Southern Africa
West/Middle Africa
South and South-East Asia
Form er Soviet Asia
Source: Barbara Mensch Trends in the Timing of
First Marriage, using Demographic and Health
Surveys from 51 countries, 1990-2001
20
0
%
5
10
15
20
25
30
35
40
1. Katzive L, 2003. Addressing the Human Rights of Married Adolescents, presented at WHO/UNFPA/ Population Council Technical
Consultation on Married Adolescents, Geneva
2. Adhikari R. 2003. Early marriage and childbearing: risks and consequences, in WHO 2003. Towards adulthood, Exploring the sexual and reproductive health of adolescents in South Asia, editors Bott S et al.
3. Miller S and Lester F. 2003. Married first time mothers - meeting their special needs, presented at WHO/UNFPA/ Population Council
Technical Consultation on Married Adolescents, Geneva.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
period because marriage is delayed to a greater
extent than motherhood.
There is evidence that couples in many parts
of the world would like to delay starting a family. There are some countries, according to DHS
figures, where six out of ten married adolescents wanted their first child within two years:
United Republic of Tanzania, Burkina Faso,
Guinea, Nigeria and Egypt.1 However, fewer
than half of married adolescents wanted to give
birth within two years in a greater number of
countries, including Ethiopia, Kenya, Malawi.
Rwanda, Uganda, Benin, Guatemala and
Bangladesh. In South Africa, Ghana, Brazil,
Colombia, Dominican Republic, Nicaragua and
Peru, fewer than one in three married adolescents wanted to give birth within two years.1 In
Haiti fewer than one in 14 married adolescents
wanted a baby within two years.1
In Senegal focus groups and in-depth interviews with more than 300 married adolescent
girls showed that, despite pressure from families, most wanted to delay the first or subsequent birth.2 Those under the age of 15 wanted
a four to five year delay, while those aged 15-18
wanted a two to three year delay. Those aged 18
or 19 were more likely to want a baby straight
away.
In Nepal married adolescents of both sexes
regard the ideal age for a girl to marry as
between 17 years 9 months and 18, while
unmarried adolescents say that girls should
wait until they are over 19.3 Most adolescents
believe that a girl should wait two years before
having a baby. Married adolescent girls said that
the ideal age to give birth is just under 20 years.
Unmarried girls and boys thought that girls
should wait until they are over 21. Most adolescents would like two or three children.
Such studies reflect wishes and aspirations.
However, younger adolescents often lack the
Childless women stigmatised
as source of misfortune
"If the couples do not have children for a few
years, the girl is called tharangi (infertile) and
is considered unlucky. The community
members will not even look at such a woman
before doing something important for fear she
will cause misfortune."
Nepalese mother
Source: Waszak C, Thapa S and Davey J. The influence of
gender norms on the reproductive health of adolescents in Nepal perspectives of youth. Published in WHO 2003. Towards
adulthood Exploring the sexual and reproductive health of adolescents in South Asia, edited Bott S et al.
ability to put these into effect. Negotiation skills
and power increase with age, education,
employment opportunities and independence.
Fear of infertility can be a significant reason
for seeking an early pregnancy. Mothers-inlaw, relatives and friends often apply overt or
subtle pressure on young married couples to
have a baby within the first year, and a newly
married adolescent wife is often anxious to
prove her fertility as a way of securing her
future. Infertility can have serious implications
for the life of a young married woman, leading
to gossip, lack of respect and poor treatment by
relatives.
A survey of 100 pregnant women in Uttar
Pradesh, India, showed that women are willing
to control their fertility through sterilisation
only after they have had what they regard as the
right number of children.4 One husband
referred to a financial crisis at home and said: "I
think that the first child should be delayed,
especially when the woman is below 19 years of
age. …But my wife does not agree. She wants a
child immediately." Condoms were rarely used
within marriage, underlining the relative lack of
control that young married couples, especially
girls, have over fertility.
■
1. Bruce J and Clark S. 2003. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy. Table 2.
2. Diop N, Myers C and Bruce J. 2003. Married adolescents: a perspective from Senegal, presented at WHO/UNFPA/ Population Council
Technical Consultation on Married Adolescents, Geneva.
3. Thapa S and Haberland N. Are married young girls and boys more disadvantaged than their counterparts? Evidence from Nepal. Unpublished document circulated at WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.
4. Barua A and Kurz K. 2001. Reproductive health-seeking by married adolescent girls in Maharashtra, India, Reproductive Health Matters Vol 9
No 17, May 2001.
21
World Health Organization & United Nations Population Fund
The risks of
early
pregnancy
E
arly childbirth can be especially risky
for adolescent girls and their babies.
Many studies report less favourable
outcomes for adolescent mothers including
higher levels of maternal mortality, the main
causes being malaria, pregnancy-induced
hypertension, puerperal sepsis and septic abortion.1 Maternal mortality in adolescent girls is
up to twice as high as for mothers aged 20-34
(Figure 5). A World Health Organization
review of adolescent pregnancy concludes that,
although adolescent pregnant girls are at
increased risk of complications, there is doubt
whether age alone is the critical risk factor for
maternal death, as it is difficult to distinguish
between the risks related to the age of the
mother and risks related to a first pregnancy.1
Adolescent first time mothers are at risk, both
because they are young and because they are
first time mothers. Low levels of education,
social status and use of health facilities are also
factors.
Girls who have babies below the age of 15
Figure 5: Maternal
mortality per 100,000
women by age in
selected countries.
Source: Safe Motherhood
Initiative Factsheet, Adolescent
Sexuality and Childbearing, 1998
appear to be at extra risk. ‘Gynaecological age’
is the number of years since menarche, and
girls with a gynaecological age of less than two
are at higher risk of obstructed labour. Girls
who become pregnant at or just after menarche
are not ready for childbirth physically or psychologically and are at higher risks of complications. The pelvis continues to grow after
menarche, and a growing pregnant girl must
compete with her baby in the womb for nutrition. The WHO review concludes, “Low gynaecological age appears to be an independent factor influencing the outcome of adolescent
pregnancy.” 1 Younger mothers are often less
psychologically prepared, especially since 60%
of married adolescents report that their first
birth is mistimed or unwanted.2
Hypertensive disease
Hypertensive disease is a leading cause of
maternal deaths. Pre-eclampsia and eclampsia
account for approximately one in seven maternal deaths in Bangladesh, one in five in Nigeria
and the Philippines, about a quarter in
Mozambique, Ecuador and South Africa, a
third in Puerto Rico and almost half in United
Republic of Tanzania.3 Pre-eclampsia complicates 5-8% of all pregnancies and 85% of cases
are in first time mothers.2
1400
1200
20-34
1000
15-19
800
600
400
200
0
Ethiopia
22
Indonesia
Bangladesh
Nigeria
Brazil
1. WHO. 2004. Adolescent pregnancy. Issues in adolescent health and development. Department of Child and Adolescent Health and
Development and Department of Reproductive Health and Research. WHO Discussion Paper on Adolescence.
2. Miller S and Lester F. 2003. Married Young First Time Mothers: Meeting their special needs, presented at WHO/UNFPA/ Population Council
Technical Consultation on Married Adolescents, Geneva. Much of this section follows the Miller and Lester analysis.
3. Duley L. 1992. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean.
Br J Obstet Gynaecol; 99(7): 547-53. Review. Cited in Miller and Lester. 2003. Op cit.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Anaemia and malaria
More than half of pregnant women are
anaemic, with much higher rates in developing
countries — 86% in United Republic of
Tanzania, 88% in India and 94% in Papua New
Guinea.1 Anaemia is frequently a product of
malnutrition, especially deficiencies of iron,
vitamin A and folic acid. Girls in many societies
are discriminated against when food is shared
within a family, and those who become pregnant while they are still growing are likely to
become anaemic if undernourished to begin
with. While anaemia alone is rarely the primary
cause of maternal or child death, it is frequently a co-factor. It has been cited as such in 40%
of maternal deaths in the Gambia.2 In India,
anaemia was found to complicate 35% of adolescent pregnancies but only 22% of the pregnancies of older first time mothers.3 This hospital-based study in India also found significantly higher rates of pregnancy induced hypertension and preterm labour in adolescent mothers.
Malaria and other parasitic diseases are also
important causes of anaemia. Malaria infection
tends to be more severe in pregnant women and
especially in first time mothers. Younger pregnant women in Kenya and Cameroon were
twice as likely as older pregnant women to have
malaria. In Mozambique, where malaria is the
leading cause of hospital based adolescent
maternal mortality,4 79% of maternal deaths in
a leading Maputo hospital were classified as
avoidable, and adolescents tended to be more
mismanaged and misdiagnosed.5 Health staff
tended to underestimate the gravity of the disease in first and young pregnancies, leading to
delays in treatment and management.
Adolescent mothers are less likely to protect
themselves from mosquito bites and less likely
to seek treatment for malaria.6
Young first time
mothers at risk
● Maternal mortality rates are
twice as high in adolescent
mothers than in older women.
● The risks are related to being
a young first-time mother.
● Very young adolescents are
physically and psychologically
unready for childbirth.
● Hypertension and anaemia
are common problems.
● Many young women are
disabled by fistulae as a result
of prolonged labour.
● There is a higher risk of poor
health outcomes for babies of
adolescent mothers.
Obstructed labour and fistula
Prolonged or obstructed labour is usually the
result of the mother having a small pelvis, or
the baby being awkwardly positioned. The risks
are greater in first time mothers, smaller
women and in very young mothers below the
age of 15. Women who have access to emergency obstetric care will have their babies delivered by Caesarean section when labour is prolonged. In poor, particularly rural areas, women
may not know when or how to seek help and
are often far from obstetric care. Adolescent
mothers usually do not have the decision-making power or the means to seek help at the right
1.
2.
3.
4.
Brabin B, Hakimi M and Pelletier D. 2001. An Analysis of Anemia and Pregnancy-Related Maternal Mortality. Journal of Nutrition; 131:604S-615S.
Hoestermann C et al. 1996. Maternal mortality in the main referral hospital in The Gambia, West Africa. Trop Med Int Health; 1(5): 710-717.
Verma V and Das K. 1997. Teenage Primigravidae: A Comparative Study. Indian Journal of Public Health. Apr--June 1997. 41(2).p.52-55.
Granja A. 2002. Maternal deaths in Mozambique: An audit approach with special reference to adolescence, abortion, and violence. Online at
http://diss.kib.ki.se/2002/91-7349-218-3/ — checked October 2005.
5. Granja ACL, Machungo F, Gomes A et al. Adolescent maternal mortality in Mozambique. Journal of Adolescent Health 2001; 28(4):303-06.
6. Okonofua F et al. 1992. Influence of socioeconomic factors on the treatment and prevention of malaria in pregnant and non-pregnant adolescent girls in
Nigeria. Journal of Tropical Medicine and Hygiene; 95: 309-315.
23
World Health Organization & United Nations Population Fund
time. Labour may continue for days with devastating results. If the woman does not receive
effective management in time she may die from
rupture of the uterus or infection. Fetal deaths
are common if obstructed labour is allowed to
continue.
In some cultures, long labour is considered
'natural' and mothers are encouraged to bear it
with fortitude. But traditional culture is also
aware of the dangers, as reflected in the
proverb: "The sun should not rise or set twice
on a woman in labour."
Prolonged obstructed labour can lead to
obstetric fistula, a disability that affects 50,000
to 100,000 mostly young and poor women each
year.1 Pressure from the baby's head kills soft
tissue around the pelvis and causes a tear
between the woman's vagina and her bladder or
rectum. In nearly all cases the baby dies and the
woman is left with a unresolved tear or fistula
which leaks urine or faeces. Most fistula
patients are under 20, poor and illiterate and
live in remote areas. A girl with an unrepaired
fistula may be deserted by her husband and
declared unclean. She can face a life of isolation,
as well as being at risk of infection, disability
and kidney disease.
In Nigeria alone, it is estimated that 800,000
women live with unrepaired fistulae,2 while in
Niger, fistula is a factor in more than 60% of
divorces.3
In 2003, UNFPA launched a Global
Campaign to End Fistula.1 The campaign seeks
to delay marriage and pregnancy and to ensure
that women have access to high quality delivery
care. The campaign also promotes better repair
of fistulae and greater understanding and
acceptance in communities. It seeks to end the
silence on this cause of pain and stigma.
UNFPA is working with EngenderHealth to
conduct surveys in African countries with a
1.
2.
3.
4.
5.
6.
24
Action against fistula
The Uganda Fistula Project and the Kuleana
Center for Children's Rights developed a
booklet to raise awareness of the dangers of
early marriage, early birth and fistula. 50,000
copies of the booklet, entitled What about my
rights?, have been sent to religious leaders,
community organizations, schools and health
centres.
Source: Miller S and Lester F. 2003. Married first time
mothers Meeting their special needs.
high prevalence of obstetric fistula to identify
the scale of the problem and to examine the
capacity and skills of health services in providing fistula surgery.4 UNFPA and the Bangladesh
government have taken steps to establish a
Fistula Repair Centre at the Dhaka Medical
College, as a training centre for South Asia.
Abortion
Between 2 million and 4.4 million of the estimated 20 million unsafe abortions each year are
among adolescent girls.5 Although married
adolescents seek abortions at a lower rate than
those who are unmarried, a decision to seek an
abortion may reflect problems between husband and wife.6 Adolescents are more likely to
seek a late abortion from an unskilled provider,
using dangerous methods.5 They are more likely to have complications and less likely to seek
medical attention. In Bangladesh, 15-19 year
old girls who sought abortions were twice as
likely to die as older women.5 In a Ugandan
study, more than half of abortion-related
deaths were in adolescent girls.5
Risk to the baby
The WHO review of adolescent pregnancy
found evidence that adolescent pregnant girls
UNFPA Campaign to End Fistula. http://www.endfistula.org/
Wall L. 2002. Fitsari 'dan Duniya - An African (Hausa) praise song about vesicovaginal fistulas. Obstetrics and Gynecology, 100(6): 1328-1332.
Lendon S. 2001. Early marriage of girls in Niger. Development Bulletin; 56: 77-9
2003 UNFPA and EngenderHealth. Obstetric Fistula Needs Assessment Report: Findings from Nine African Countries
Olukoya et al. 2001. Unsafe abortion in adolescents. Int J Gynaecol Obstet; 75(2): 137-147
Singh S. 1998. Adolescent childbearing in developing countries: a global review. Stud Fam Plann; 29(2): 117-136.
NB: 2, 3 and 5 are cited in Miller and Lester, 2003. Married Young First Time Mothers: Meeting their special needs, presented at
WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
A young patient at the Ethiopia Fistula Hospital. Girls who have babies under the age of 20 are at higher risk of
obstetric fistula. This girl’s condition was treated, but obstetric fistula often goes untreated, causing adolescent
girls to live with disability, stigma and isolation.
Picture: WHO/P Virot (WHO-208391)
are at increased risk for preterm delivery and
that the youngest age groups run the highest
risk.1 The review finds that adolescent maternal
age appears to be an independent risk factor for
preterm birth,and thus for low birth weight.”1
In developing countries, if a mother dies in
childbirth her baby is unlikely to survive. Most
newborn deaths are due to infections at birth
(neonatal tetanus and sepsis) or shortly after
birth (pneumonia, diarrhoea).2 About a third
of newborn deaths are due to birth asphyxia
and trauma.
Prematurity on its own causes 10% of newborn deaths. Miller and Lester say, “Babies
born to young mothers are at increased risk of
neonatal and infant death. Though the cause of
this increased risk is thought to be multifactorial, preterm delivery is thought to significantly
contribute to this risk.”3
■
Making hospital practices
relevant to adolescents
20,000 women a year deliver their babies at
El-Galaa Teaching Hospital in Cairo, Egypt,
A survey showed that this busy hospital was
not always adolescent friendly, and practice
was not always evidence based.
The hospital is working with the Population
Council in Egypt to make delivery and
postnatal services more appropriate to the
needs of adolescent mothers.
An improvement programme aims at
ensuring, for example, that women always
have their blood pressure taken on arrival, so
that any hypertensive disease will be detected
early. Doctors are asked always to introduce
themselves to patients and to call women by
their names.
Source: Population Council, Reproductive Health
Program
1. WHO. 2004. Adolescent pregnancy. Issues in adolescent health and development. WHO Discussion Paper on Adolescence.
2. WHO. 1996. Mother- baby package: Implementing safe motherhood in countries. Practical Guide.
3. Miller S and Lester F. 2003. Married Young First Time Mothers: Meeting their special needs, presented at WHO/UNFPA/ Population Council
Technical Consultation on Married Adolescents, Geneva.
25
World Health Organization & United Nations Population Fund
Married
adolescents
miss out on
health care
M
arried adolescents have health
needs as young women, as
young wives and frequently as
pregnant women and young mothers too. They
often miss out on services for adolescents
because they are married and for married
women, because of their age, lack of experience
and lack of autonomy. While their health service needs are the same as those of other adolescents and other married women, special efforts
may be needed to ensure that they know about
services and can access them. This means raising the awareness of family members who may
act as gatekeepers to services.
Married adolescents need to be well informed
about protecting their health and to have the
skills, means and support to use information.
They require support from family members
who make decisions about how food is shared
and how health care is sought. Diet and nutrition, not smoking, avoiding smoky atmospheres, and not using alcohol are important.
Married adolescents should know about immunization, hygiene, the prevention of sexually
transmitted infections (STIs) and HIV and
AIDS and about how to seek treatment. It is
important that married adolescents know how
and where to obtain reproductive health care,
including during pregnancy and childbirth.
Married adolescents often have little knowledge about or control over care while they are
pregnant, when delivering their babies, or after
the birth.1 Especially in rural areas, many pregnant women give birth without the attention of
26
Need for information,
autonomy and care
● Married adolescents need
better information about their
health care needs and support
to access care.
● They need to be able to
make choices about how to
protect their health.
● They should know how to
prevent STIs and HIV and how
to seek treatment.
● When pregnant, they need
access to antenatal, delivery
and postpartum care.
● Adolescents lack the
knowledge, autonomy or power
to seek medical care.
● Husbands and mothers-in-law
can help married adolescents to
access care.
skilled provider. The low status of adolescent
mothers and their lack of income means they
are dependent on others — typically husbands
or mothers-in-law — for access to care.
This may lead to health needs being neglected. In Egypt, adolescents received antenatal care
less and later than older mothers.2 One study
from India showed that married young first
time mothers who returned to their own mothers’ homes for care, were more likely to survive
delivery than whose who remained in their
married home.3 Antenatal care, a skilled delivery attendant and postpartum care can reduce
the number of mother and baby deaths.4
1. This section is partly based on Miller S and Lester F. 2003. Married Young First Time Mothers: Meeting their special needs, presented at
WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.
2. Galal. 1999. A comparison between adolescents (15-19 years) and 20-24 years old mothers in Egypt and Sudan. League of Arab States Population Research Unit. Arab Conference on Maternal and Child Health.
3. Santhya KG and Jejeebhoy SJ. 2003 . Sexual and Reproductive health needs of married adolescent girls. Economic and Political Weekly
October 11, 4370-4377 (Cited by Miller and Lester 2003. Op. Cit.)
4. WHO. 2004. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Married adolescents, mothers-in-law and husbands:
complex decision-making in seeking care
In India, married adolescent girls often delay seeking treatment for reproductive tract
infections. Sexual matters may be "shrouded in a culture of silence, embarrassment,
shame and blame".1 In one study in Uttar Pradesh, 56% of pregnant women deferred
decisions about health issues to their mothers-in-law and 15% deferred to their husbands.2
A study in Maharashtra surveyed 302 married adolescents aged 15-19, two-thirds of whom
had experienced at least one pregnancy. Husbands and mothers-in-law were also
surveyed.1 About 80% of wives and many husbands wanted to limit their families to two or
three children. Mothers-in-law agreed, but wanted the first baby to be conceived within the
first year of marriage. Many opposed modern methods of birth control.
Almost all (97%) of girls sought treatment for complaints such as coughs, colds, fevers,
chills or headaches, but only half sought treatment for gynaecological problems. A third
turned to their own mothers for help with menstrual problems. Mothers-in-law wanted
daughters-in-law to confide in them, but many were sceptical about ‘minor illnesses’. One
said: "I think she fakes all these complaints. Maybe she is not able to cope with the work
and this is her way of getting rest." Married adolescents with vaginal discharge, itching,
bad odour or pain during sex were more likely to talk to husbands, who were, however,
reluctant to discuss them, and expected their wives to seek care themselves.1
In a follow up study (2001), three quarters of husbands said that pregnant women should
seek antenatal care. Most said that they wanted to participate, but only half accompanied
wives to clinics for routine care.3 Husbands who did accompany wives to the health centre
often had to wait outside because of staff attitudes or lack of facilities.
A further report (2004) concludes,4 "…young newly-married women experience pregnancy
and childbearing in an environment where they have little or no autonomy in decisionmaking, finances, or mobility to seek care. Thus, it may be crucial to get husbands
involved, since husbands are often the decision-makers, the ones who have to accompany
the young woman to the clinic, and the ones who pay for care. However, the same report
also suggests that women themselves may not want their husbands to be present; and the
health system makes it hard for husbands to be present."
1. Barua A and Kurz K, 2001. Reproductive health-seeking by married adolescent girls in Maharashtra, India. Reproductive Health
Matters May 2001 9:17 53-61.
2. Prakash A,Swain S and Negi K. 1994. Who decides? Indian Pediatrics 31(8):978-80.
3. International Center for Research on Women and Foundation for Research in Health Systems 2004. Update 1: Husband's
Involvement in Maternal Care: Young Couples in Rural Maharashtra.
4. Barua A. et al. 2004. Caring Men? Husbands' Involvement in Maternal Care of their Young Wives. Economic and Political Weekly,
December 25, 2004: 5661-5668.
27
World Health Organization & United Nations Population Fund
Lack of awareness and fear of stigma deter young
married women from seeking treatment
In a study of 451 married girls and women aged 16-22 in Tamil Nadu, India, more than half
had experienced a gynaecological problem or urinary tract infection, but few had sought
treatment. Laboratory tests showed that 38% of the women had a reproductive tract infection
(RTI), including 15% who had an STI. Of 211 women who reported no symptoms, 63 (30%)
had clinical evidence of RTI. 50 later agreed that they had had symptoms — 23 had regarded
them as ‘normal’, while 27 had been reluctant to discuss their problem.
Of those who had experienced gynaecological problems, almost two thirds (65%) had sought
no treatment, citing lack of a female health care worker, lack of privacy at the health centre,
distance from home, or lack of concern over symptoms. Of those who did seek treatment,
21% used home remedies or traditional medicines, 57% used unqualified private practitioners
and 13% went to the Community Health and Development (CHAD) hospital in Vellore town.
Only 9% used government primary health centres.
Researchers comment, “The proportions with STIs are surprisingly high, given the
conservative attitudes about extramarital relationships in India. Most of the women were likely
infected only within marriage, because most women, particularly in rural India, are not
sexually active prior to marriage.” They conclude: "The reasons given for not seeking care
were similar to those reported in other studies in India: stigma and embarrassment, lack of
privacy, lack of female doctors at health facilities and treatment cost."
Source: Prasad J et al. 2005. Reproductive Tract Infections Among Young Married Women in Tamil Nadu, India. International Family
Planning Perspectives Vol 31 No 2 June 2005.
During antenatal care, anaemia can be detected, and supplements of iron, vitamin A and
folic acid as well as tetanus immunization can
be provided. Conditions such as malaria or
hookworm can be detected and treated.
Most maternal deaths occur because of late or
inadequate intervention, often due to one or
more of “the three delays” in:
◆ recognizing complications and seeking care
◆ reaching an appropriate health care facility
◆ receiving good quality care at a facility1
During delivery, women need the presence of
a skilled attendant with midwifery skills. In an
emergency the attendant can refer women with
haemorrhage, eclampsia or prolonged and
obstructed labour, to a facility for emergency
28
obstetric care, including Caesarean section or
blood transfusion. Referral for emergency care
requires planning and money for transport and
treatment. WHO recommends that all pregnant women have a birth plan that covers these
eventualities,2 but married adolescents need
support to make such a plan.
Postnatal care includes support for breast
feeding, treatment of complications and family
planning information and services.
Seeking care is a learned experience, so that
lack of knowledge, lack of autonomy and lack
of resources are significant obstacles with longterm effects. Communities need to create environments that encourage married adolescents
to use services appropriately.
■
1. WHO. 2003. Press release: Maternal deaths disproportionately high in developing countries. October 2003.
2. WHO. 2003. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice.
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
Programmes to
reach married
adolescents:
programmes to
delay marriage
M
ost programmes for adolescents do not reach married
women while most services for
married women do not reach adolescents.
Married adolescents do not know what services
are available or how to access them, while service providers are largely unaware of married
adolescents as vulnerable young people.
Married adolescents at home are rarely included in surveys of adolescent needs.
Family life education does not reach married
adolescents, because it is usually given in
school. Peer to peer programmes do not think
of married women as 'peers' of adolescents and
fail to include them. Maternal and child health
services rarely focus on young first time mothers. Married adolescents do not require special
services, but do need positive action to achieve
equality of access.
Most HIV and AIDS services fail to address
the special needs of married adolescents girls, a
significant ommision in a population of girls
about to start child-bearing. Successful prevention can protect the adolescent girls themselves,
prevent transmission of HIV and AIDS to their
babies and prevent children becoming orphans,
as well as providing an entry point for programmes for their husbands.
Adolescent programmes to reduce the risks of
HIV usually encourage them to abstain from
sex, to reduce sexual frequency, to change to a
safer partner, to use a condom or to have a
mutually monogamous relationship with an
uninfected person. These are not realistic
options for married adolescents, especially
Married adolescents slip through the service net
◆
In Nepal, married pregnant adolescents attended antenatal facilities at lower rates than
older women even in urban areas where health facilities were within easy reach.1
◆ In Senegal, Project Promotion des Jeunes for out of school adolescents, focused on peer
education in the community, at youth centres and health services. It reached unmarried
males and some adolescent girls but hardly any married adolescents. A UNICEF/UNFPA
programme in Senegal targeted neglected adolescent girls but found that only 6% of
clients were married. Most married adolescents lacked the mobility to attend.2
◆ In Ghana, the Navrongo project has recognized an urgent need to address married
adolescents, who are less likely than unmarried girls to use condoms and more likely to
believe that they have no chance of contracting HIV.3 More than 30% of adolescent girls
are married but they made up less than 15% of adolescents reached in a survey.
1. Adhikari R. 2003. Early marriage and childbearing: risks and consequences, in WHO. 2003. Towards adulthood, exploring the sexual
and reproductive health of adolescents in South Asia, edited by Bott S et al.
2. Diop N and Meyers C. 2003. Married Adolescent Girls’ Lives: A Perspective from Senegal. Population Council.
3. Debpuur C. 2003. Married Adolescents in the Kassena-Nankana District. Navrongo Health Research Centre presented at
WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents, Geneva.
29
World Health Organization & United Nations Population Fund
when couples are trying to start a family. Most
married adolescent girls already practice
monogomy, but they can rarely know their husband’s HIV status or be able to ensure two-way
fidelity within marriage. As a result in many
parts of the world, marriage and long-term
monogamous relationships do not protect
women from HIV.1
A human rights agenda
to delay marriage
The most significant improvement in the
prospects for adolescent girls would be to delay
marriage. Adolescence is a time of preparation
for adulthood — for work, marriage and parenthood. Early marriage truncates that process.
Younger adolescents who attend school can
acquire skills, develop their autonomy, and
learn to interact effectively with others, so that,
as adults, they can take decisions about their
lives, earn an income and feed their families. A
strategy for delaying marriage can focus on the
human rights of girls and especially the rights
to non-discrimination, equity, participation
and empowerment. States that ratify the
Convention on the Rights of the Child, the
Convention on the Elimination of
Discrimination Against Women, and the
Covenants on Civil and Political Rights and on
Economic, Social and Cultural Rights have an
obligation to promote, observe and protect the
rights of adolescent girls to childhood, to education, to have their views taken into account,
and to protect them from too early marriage.
Gender equality, education
and safety for girls
Goal 3 of the Millennium Development Goals
is to “promote gender equality and empower
women”. Delaying marriage contributes to this
by giving adolescent girls more opportunity
and choice, and more autonomy to take deci-
30
1. UNAIDS. 2004. Women and AIDS – A Growing Challenge. Fact Sheet.
2. See http://www.unfpa.org/icpd/targets.htm
Cairo project offers
incentive to delay
marriage to 18+
The Moqattam Project works with
communities involved in garbage
collection in Cairo.
The Project set up a Crisis Committee to
counsel families who plan to marry
daughters below the age of 18 against
their will. It seeks to resolve disputes
between parents and daughters and
offers incentives to prevent underage
girls from being married. Some young
girls tried to harm themselves when they
learned of marriage plans.
The Crisis Committee offers 500 Egyptian
pounds (about $150 US) as a wedding
present to any girl who is aged 18 years
or older on her wedding day.
Between 1995 and 2003, 112 girls
successfully claimed this prize. No girl
involved in the project was known to have
married before the age of 18.
Source: Assaad M and Bruce J. 1997. Empowering the next generation: Girls of the Moqattam garbage settlement.
Population Council, Seeds 19.
sions and to put them into effect. The UN set a
target to eliminate gender disparity in all levels
of education by no later than 2015. The indicators to test progress are:
◆ The ratio of girls to boys in primary
education
◆ The ratio of literate females to males
aged 15-24
◆ The proportion of women engaged in wage
employment outside agriculture
◆ The proportion of seats held by women in
national parliaments2
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
In East Asia, where a decline in early marriage has been driven by rapid social and economic change, an increase in secondary education for girls is a particularly telling factor.1 In
South Asia also, education has proved important. Sri Lanka has one of the lowest rates of
maternal mortality, and most deliveries are
supported by a skilled birth attendant at a
health facility. Supportive factors include government commitment to improving education
and health care, the relatively high status of
women, and high female literacy rates. Adult
literacy rates among women are 88% and girls
have access to free education up to university
level. By 1993, the age of marriage had risen to
25, with women able to take advantage of family planning and maternal health services.2
However, swapping the risks of early marriage for the risks of coerced unprotected sex
outside marriage will not be acceptable to girls,
families or communities. If communities are
going to change customs of early marriage, girls
need safe places in their social environment.
Safe places can be schools and colleges and
training centres, and these can also offer girls
greater opportunities for autonomy.
Achieving a safe social environment also
means working with young men, particularly
about relationships and marriage and the protection of women from coerced sex inside or
outside marriage.
Reduce the age gap
Girls who delay marriage are more likely to wed
men nearer to their own age. In areas where
STIs and HIV are risks, families need to know
that the more years of sexual experience that a
man has, the greater the risk that he may be
infected. If purity is important within communities, it should be as important for men as
for women. Mutual fidelity is also important
within marriage.
Make the first year of marriage
a place of safety
Give marriage a 'health dowry'3
Marriage celebrations can include important
health information. In China, along with the
offical congratulations, couples are sent details
of local maternal and child health clinics.
Preparation for marriage can be an opportunity for a couple discuss whether to get tested
for HIV and to find out their status. An uninfected partner in a discordant couple can be
Education leads to later marriage and better care
“Educated girls are likely to marry later — especially if their schooling extends to the junior
secondary level and they engage in economic activity outside the home. Educated girls and
women also have fewer children, seek medical advice sooner for themselves and their
children and provide better care and nutrition for their children.
“Such behaviour reduces the possibility of disease and increases the odds of children
surviving past age five. Over time reduced child mortality leads to smaller families and
increased contraceptive use — lowering overall fertility. With smaller households child care
improves, and with lower fertility the school age population shrinks. Thus the benefits of girls'
education accrue from generation to generation."
Source: United Nations Development Programme (UNDP) 2003. Human Development Report 2003.
1. Malhotra A. Variations in the meaning of marriage: Historical and cultural Perspective. Presented at WHO Technical Consultation, Geneva.
Dec 2003.
2. WHO, UNICEF, UNAIDS, WORLD BANK, UNESCO, UNFPA. 2000. Health a Key to Prosperity - Success Stories in Developing Countries.
See http://www.who.int/inf-new/mate1.htm
3. This idea of a health dowry for marriage was put forward by Martha Brady and Judith Bruce of the Population Council at the
WHO/UNFPA/ Population Council Technical Consultation on Married Adolescents in Geneva in December 2003.
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World Health Organization & United Nations Population Fund
protected. Couples can also be tested for other
sexually transmitted infections and, if necessary, treated before marriage.
Mutual testing leading to mutual trust can be
both a 'health dowry' and a 'health brideprice',
reassuring both partners that marriage is
indeed a place of safety. Health and social care
providers should also ensure that married adolescent girls and family members who act as
gatekeepers know how to access services.
Delay pregnancy — the role of condoms
There is scope to present the first year of marriage as a place and time of safety, where the
couple protect themselves against STIs and
HIV, and delay the first pregnancy, which is
what many couples say they want.
Condoms can help to make the first year of
marriage a time and place of safety. Currently
only the male or female condom protects sexually active girls against STIs and HIV. Bringing
condoms across the bridal threshold is difficult
in many cultures, where they are used mainly
for sex outside stable relationships.
STIs in some regions are among the most
common causes of illness, with far-reaching
consequences including the potential for infertility in women. Infertility is a major concern of
young brides, of husbands and of mothers-inlaw, and there is an erroneous belief in some
Proclaiming an end to FGC, child marriage and forced
marriage in Senegal and Guinea
Religious and cultural leaders in Matam Region, northern Senegal have made declarations in
front of hundreds of people that their communities would abandon female genital cutting
(FGC) and early and forced marriage.
The NGO Tostan — the name means breakthrough in the Wolof language — incorporated
human rights discussions into education, literacy and micro credit projects in more than 400
villages in Senegal and Guinea, in a traditional Muslim farming area known as the Fouta.
At first some religious leaders opposed the changes and some men burned tyres in protest
against Tostan. But religious and traditional leaders who met in Ourassougui in July 2003
decided there was no religious justification for FGC or for early or forced marriages. They
called for an end to these practices in the name of better health and human rights.
Communities now support the changes. In October 2003, village representatives joined in a
public declaration in Sedo Abbas in front of religious leaders, village chiefs, the Governor of
Matam, the Swedish Ambassador and journalists. School children performed plays to show
the effects of FGC and early forced marriages. In May 2005, 44 villages Kolda region, made
a similar declaration, following an 18 month consultation with girls and women, boys and
men, traditional and religious leaders, and traditional cutters. In the past girls were married by
their relatives as early as 12 years old. This has now been prohibited.
Source: Tostan Women’s Health and Human Rights web site: http://www.tostan.org/
32
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
communities that it can be caused by using
contraceptives. Promoting condoms to protect
fertility could help to dispel such myths and
make condoms a more acceptable form of contraception.1 A husband and wife who use condoms during the first year of their marriage,
would be more likely to continue to use them
for birth spacing and protection.
Improve nutrition for girls
Girls are often the least well fed in many families, although they need good nutrition to grow
up strong and healthy and to become mothers.
A better understanding within marriage of the
nutritional needs of girls is a long-term goal. In
the short-term, nutritional supplements can be
given in school or at any point when adolescent
girls come into contact with health services.
Even when given during the second half of
pregnancy, malarial drugs and iron and folic
acid supplements have shown benefits.2
Adolescent friendly services for
married adolescents too
Married adolescents are less likely than older
married women to receive health care. A study
in Sudan found that girls who are poor, still at
school or under 18 are less likely to attend a
health facility.3 Health services need to be safe,
welcoming and accessible. Married girls require
affordable services that provide information,
reassurance and clinical expertise. Adolescent
friendly health services not only help to deliver
the human rights of married adolescents, but
also best use of health resources by reaching
this critical group within the population.4 ■
India: opening communication for young married
couples
The First Time Parents Project in Gujarat and West Bengal, India, works with young couples
to improve communication between husband and wife, reduce isolation, improve knowledge
of reproductive and sexual health and help the couple to act in their best interests.
A survey showed that more than a third of couples in Gujarat and well over half in West
Bengal felt that they had married too early, and that adolescent wives had the least freedom
of movement, involvement in decision making and reproductive health knowledge.
Male and female health workers and peers hold separate sessions with husband and wife,
and senior family members. There are neighbourhood meetings for husbands, and meetings
of young women's groups for wives. One key aim is to improve the use of antenatal services,
and their quality. If the wife is pregnant the couple is urged to make a birth plan, including
provision for emergency transfer if this is needed. The project works to keep the community
involved and encourages health NGOs to include social issues in their support. The young
wives learn about loans as well as about nutrition and reproductive health.
The First Time Parents Project is a collaboration between the Population Council, the Child in Need Institute in Calcutta, West
Bengal, and the Deepak Charitable Trust in Baroda, Gujarat,
1. Martha Brady. Reproductive Health Matters 2003; 11(22): 134-141. Preventing Sexually transmitted infections and unintended pregnancy and
safeguarding fertility — triple protection needs of young women.
2. Harrison K et al. 1985. Growth During Pregnancy in Nigerian Teenage Primigravidae. British Journal of Obstetrics and Gynecology;
5(Supplement): 32-39. Cited in Miller S and Lester F. 2003. Married Young First Time Mothers: Meeting their special needs.
3. LeGrand and Mbacke. 1993. Teenage pregnancy and child health in urban Sahel. Studies in Family Planning, 24, 137-149
4. WHO. 2003. Adolescent Friendly Health Services, An Agenda for Change.
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World Health Organization & United Nations Population Fund
Bangladesh: youth clubs for young married couples
In Bangladesh, three quarters of girls are married by the age of 18 and the median age of
marriage is 14. An analysis by UNFPA and UNICEF revealed that married adolescents are an
underserved group, invisible to governmental and NGO health services alike.
The Population Council and UNFPA with the Ministry of Sports and Youth, Ministry of Health,
Ministry of Women's and Children's Affairs, UNICEF and NGOs set up youth clubs for young
married couples in ten districts across the country. The aim was to train peers to deliver
social education and to encourage married female adolescents to use health services. The
project also set out to educate community and religious leaders about adolescent
reproductive health, and to encourage health service providers to provide youth friendly
health services to married adolescents.
Each youth club selects two male and two female leaders — often husbands and wives. Each
leader then selects 30 married girls and their husbands from each sub district to become
peer leaders. Peer leaders receive five days personal and social education in which they
learn about reproductive rights, sexual health and personal hygiene, family planning and safe
motherhood. They also learn how to build a good relationship between husband and wife.
Peer leaders pass on this knowledge to club members.
Source: Rob U. 2003. Married Adolescents Project: What do we know? 2003 presented at WHO/UNFPA/ Population Council Technical
Consultation on Married Adolescents, Geneva.
Outreach draws young women into services
As part of the Action Research and Training for Health Program (ARTH) in Rajasthan, India,
first time mothers, most of whom are adolescents, receive special attention from trained
midwives. An outreach program has set up a system of village women volunteers who get to
know every first-time pregnant mother in their village and accompany them on their first visit
to the clinic.
The service provides a 24-hour delivery service at home and at the health centre. It includes
an obstetric flying squad comprising a nurse midwife and a male field worker on a motorbike.
They can reach women in remote villages and, in an emergency, arrange transport to
hospital. Once women have been in contact with the services they are more likely to also use
postnatal and child care services. Services promote the involvement of expectant fathers and
fathers of young infants.
Source: Miller S and Lester F. 2003. Married first time mothers Meeting their special needs.
34
MARRIED ADOLESCENTS
NO PLACE OF SAFETY
India: life skills encourage girls to delay marriage
In India the International Center for Research on Women (ICRW) supports local organisations
to work with married couples and single girls. The aim is to delay marriage where possible
and to improve the knowledge and understanding of those who are already married.
In rural Maharashtra, unmarried girls aged 12-18 are offered Life Skills, one hour a day, five
days a week for a year taught by a village woman who has completed seven years of
schooling. The course, designed by the local Institute for Health Management-Pachod
(IHMP), targets girls who have left school and who are working. Families agree not to marry
off the girls while they are on the course. Only 9% of those who complete the course marry
below the age of 18, compared with 22% of girls who complete part of the course and 29% of
girls who never enrol. 2,000 girls from 72 villages and 30 areas of Pune city have enrolled.
This is part of a wider programme of work with adolescent girls. Other courses have resulted
in increased knowledge of reproductive and sexual health and an increased confidence on
the part of girls to tell their parents what they do and do not want from marriage. Work with
married couples found that many were prepared to use contraceptives for a year, but after
that they were fearful that they would be thought to be infertile.
The overarching lesson that ICRW draws from the work is that reproductive and sexual
health is not only an issue for the adolescents, because they do not have the power to take
decisions. It is a community issue and it is important to engage husbands and mothers-inlaw. Communities are now asking for the projects to be expanded.
Source: IHMP and ICRW. 2004 Increasing Low Age At Marriage in Rural Maharashtra, India Update 1.
Nepal: participatory approach reduces early marriage
In Nepal, EngenderHealth and ICRW worked with local NGOs to engage urban and rural
adolescents and key adults, such as mothers-in-law. Extensive needs assessment was
conducted at study sites, followed by action planning with the community to design the
programme. Over one to two years, interventions included adolescent-friendly services, peer
education and counselling, information and education, adult peer education, youth clubs,
street theatre, economic development and teacher education. The programme helped to
increase the rate at which early marriage fell in urban areas. Although the number of girls
who married aged 14-21 fell only slightly in the rural study area, this was a significant
improvement on the rural control area where the number of married girls rose.
Source: Mathur S, Mehta M and Malhotra A. 2004. Youth Reproductive Health in Nepal — Is Participation the Answer?
EngenderHealth and ICRW
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World Health Organization & United Nations Population Fund
36
Every ten years, 100 million married adolescents
need services and support
Girls’ exposure to early, unwanted sexual activity, early pregnancy, reproductive tract
infections (RTIs) and HIV has been widely recognized since the 1994 International
Conference on Population and Development. However, many programmes are focused
on unmarried adolescents and fail to recognize the huge numbers of girls who are
married below the age of 18.
The World Health Organization, the United Nations Population Fund and the Population
Council convened a Technical Consultation on married adolescents in Geneva in
December 2003 to address this gap in understanding and programming. The meeting
looked at key messages from research and best practice from programmes and at ways
to draw this significant problem to the attention of policy makers and programme
planners. This document is one outcome of that meeting.
This document looks at what we mean by early marriage, and how, although it is
declining around the world, 100 million girls will marry before their 18th birthday over
the next ten years. As a result of early marriage, many adolescent girls are having
unsafe sex within marriage, with an older and sexually experienced man who may be
infected with a sexually transmitted infection, or HIV. It notes how, in many countries,
the time gap between getting married and having a first baby is declining. It outlines
the risks of too early pregnancy and explores the reasons why families and
communities feel under pressure to continue the practice of marrying off their
daughters while they are still adolescents.
Married Adolescents : No Place of Safety explores how health services for married
women and for adolescents fail to reach married adolescents, who are often almost
invisible. The document also describes programmes around the world that seek to
reach married adolescents with health services, and programmes that are designed to
to delay marriage .
ISBN 92 4 159377 6
© 2006 World Health Organization, 20 Avenue Appia,
CH-1211 Geneva 27, Switzerland.